The purpose of this course is to instruct on the basic anatomy and physiology of diabetes, its causes, effects and preventive measures and the health care workers role in the care of the patient with this disease.
To say it in simple term's diabetes is a disorder that prevents the body from breaking down sugar properly. It is a disease that impairs the body’s ability to use food, and alters the production of the hormone insulin, which is produced by the pancreas and helps the body change food into energy. People with diabetes can not produce the insulin or their body can not use the insulin properly. We can go to Mosbys dictionary and it will tell you that diabetes; is a complex disorder of carbohydrate, fats, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secreted by the beta cells of the pancreas or of the insulin receptors.
What is the pancreas?
The pancreas is elongated pinkish gray nodular gland that stretches across the frontal portion of the abdomen. The pancreas secretes many substances such as; digestive enzymes, insulin, and glucagon. The pancreas is divided into the head, a body, and a tail. In the adult the pancreas is approximately 13 cm long. This gland is composed of exocrine (to secrete outward through a duct, to the surface of an organ or tissue) and endocrine tissue (a ductless gland that secret right into the blood stream, effecting the function of other target organs). The pancreas contains beta cells, these cells have a vital job, they make insulin. In Type one diabetes the beta cells are destroyed somehow. Many times it is a mistake made by cells that normally protect your body from microorganisms turns against you and attack and kill the beta cells. Without beta cells there is no insulin, allowing sugars to build up in the blood.
What is Insulin?
Insulin is a powerful hormone secreted by the beta cells in the island of langerhans located in the pancreas. Insulin plays a major role in metabolic processes of the body by controlling the storage and usage of ingested fuels. Following food intake, or increased glucose (a simple sugar found in foods). The beta cells are stimulated by the increased level of glucose in the blood and then they secrete insulin. The insulin then lowers the blood glucose level and promotes transportation and entry of glucose into the muscle cells and other tissues. When there is decreased insulin and or no insulin secreted this leads to elevated blood sugar and lipid (fats) levels Diabetes Mellitus is a major concern in the United States today. Diabetes effects over 11 million people. It is one of the highest causes of death in our country. According to the National Diabetes Data Group 5.8 million cases have been reported and there are thousands more undiagnosed. A diabetic's life expectancy is cut by one third and the disability rate related to the disease is 2-3 times higher than it is in the general population. Diabetes is more prevalent in the elderly. Blacks, Hispanics and Asian’s have a higher diabetic rate then Caucasians do. Some Indian tribes have the highest rate in all of the world, 20-50 % of their adult population end up with diabetes.
The economic cost of diabetes continues to rise. This is due to the increasing life expectancy. Cost directly related to diabetes are conservatively estimated at 13.8 billion a year. If we add in all the complications related to the disease the cost would double. Adults with diabetes are hospitalized 2.4 time's more frequently then other adults and children with diabetes are admitted into hospitals 5.3 times more frequently then the general population. These hospitalizations are related to the many complications associated with diabetes.
The etiology of this disease is not fully understood. There are probable causes, and each varies from patient to patient. They are:
Inherited Factors (Genetics)
Type 1 and type 2 diabetes has a genetic component, the factors differ in each type. They both carry a positive HLA antigen in their tissue typing, but not all people who test positive for this factor get active diabetes. We can use this typing to find persons at possible risk for the disease. If you follow case studies of diabetic’s it will show a very high inherited factor. This does not show any particular pattern from whom to whom, it can even skip a generation or two.
Although viruses have been indirectly associated with diabetes for many years, it was not until 1965 that viral research showed a greater association between the two.
The genetic makeup of the person's cells will tell if the virus can attach it self to the cell or not. A sudden appearance of insulin dependent diabetes can be a result of an infection with the diabetogenic virus. This is more common in a person who is already predisposed, and if they are in poor health this can increase their chances. Insulin dependent diabetes many times occur suddenly and at the time of year when viral infections are frequent.. There is no relationship between a virus and type 2 diabetes.
Persons at Risk for Diabetes
1.) People with a family history of the disease.
2.) Obese people.
3.) Mothers who deliver large babies (over 9 lb.)
4.) Persons with early on set of arteriosclerosis.
a) Premenopausal women with myocardial infarction.
b) Men having myocardial infarctions before 40 yr..
5.) Persons with frequent and chronic infections.
6.) Persons with opathies; retinopathy, neuropathy, nephropathy, or other vascular manifestations.
TYPE 1 DIABETES; ( insulin dependent diabetes, IDDM) This is the most common chronic disease found in children and young adults. nearly one in every 600 children develop diabetes. The body destroys the insulin (beta) cells within the pancreas that are suppose to produce insulin, therefore the pancreas does not do it’s job and insulin is not secreted. Insulin is necessary for the body to be able to use sugar. Sugar is the basic fuel for the cells in the body, insulin takes the sugar from the blood and puts in within the cell. When sugar builds up in the blood instead of going into the cell, two things can happen. Right away your cells become starved for energy, and over a period of time high blood sugar levels will hurt your eyes, kidneys, nerves, and heart. This child would then need to be given daily insulin injections. The onset is rapid. This is many times a genetic inherited disease.
TYPE 2 DIABETES ( Non-insulin diabetes)
This type of diabetes most often occurs in adults over the age of forty. Approximately 90-95 % of adults with diabetes have type two. In type two, the pancreas still secretes insulin, however the body can not use it effectively or it does not secrete enough insulin to do it’s job. Other times the beta cells take on a nonsensitivity and fail to respond hence they do not produce insulin. This type of diabetes has a slow onset and is much more stable then type one.
This type of diabetes occurs during pregnancy. Gestational comes from the Latin word gesture, which means to bear.
these are women who’s glucose intolerance develops during pregnancy. These women many times have very large babies ( over 9 lb.). They also have a potential for becoming a type 2 diabetic after the birth of their child.
OTHER WAYS TO LOOK AT IT..
High Blood Sugar (hyperglycemia) -
When blood sugar levels get too high (this varies with each person). Keeping blood sugar between 80 and 140 is a good goal. If the blood sugar goes above 140, it may begin to cause damage.
When blood sugar is too high they can not even be read with a glucometer. A glucometer is a machine used to test blood sugar. A person can use the machine in the privacy of their own home. They must be taught how to use it correctly. Blood sugars can become a tiresome and painful chore. In some case's finger sticks have to be done three times a day. The tip of the finger is punctured using a lancet, a lancet holder, a drip of blood is applied to a strip, which in turn is placed into the glucometer. The machine will count down and give you a blood sugar reading. Many times the machine will read too low or too high. If the person is not showing any signs of low or high blood sugar you might want to reassess the quality of the test and repeat if necessary. The glucometer can usually read as high as 400 and as low as 0.
Some people still use urine dip sticks. You would obtain a small urine sample from the patient, dip the stick, match the color and assess the level of blood sugar. This way is not as accurate.
Symptoms of high blood sugar are: • excessive thirst • frequent urination • fatigue • blurred vision
Ketoacidosis is caused by very high levels of ketones in blood and urine. Ketones are waste products that build up when the body burns fat for energy. Here are some of the following symptoms: • dehydration • vomiting • drowsiness, labored breathing • abdominal pain • fruity-smelling breath
* Unless treated promptly, ketoacidosis can lead to a diabetic coma.
Low Blood Sugar (hypoglycemia) --
When blood sugar levels get too low the body gets too much insulin or too little food. It is the most common problem in children with diabetes. Symptoms include: • trembling • dizziness • hunger • crying • sleepiness • clumsiness • pale skin • headaches
Low blood sugar can be treated by giving the person carbohydrates, such as hard candy, fruit juice, regular soda, followed by a snack of crackers with cheese or peanut butter, half a sandwich, cereal with milk.
You want to avoid too much sugar at one time, this can cause a quick rush of high, and then a quick drop into a low. (as we use to do with orange juice and packets of sugar)
The goals of diabetes treatment; • to maintain normal growth and development for childhood diabetes. • to keep blood sugar levels within a target range (not too high, not too low) as much as possible. • to promote emotional well-being. • To keep person as healthy as possible, this including all body systems.
Keeping blood sugar levels in a target range means balancing insulin, food, and exercise. Remember food raises blood sugar levels, while insulin and exercise lower them.
A good diabetes treatment plan includes: • eating healthy and on schedule. • checking blood sugar levels regularly. • adjusting insulin as blood sugar levels and activities warrant. • exercising regularly.
Ideas about how to treat diabetes has changed in recent years. Diabetes treatment plans are more flexible than they used to be. Treatment is geared to the needs of the individual.
Most insulin dependent diabetics manage diabetes with two or three insulin shots a day. Insulin should be given at regular times each day. Different kinds of insulin work in different ways, Short acting can start very quickly whereas insulin’s such as NPH can have effects that are prolonged up to 12 hours. This is one reason that encouraging diet and documentation of intake is so important. If a person is given a long acting insulin and does not eat many complications can occur. Many people take more than one kind of insulin and education is extremely important. The type of insulin the person uses and the times it is taken will depend on each individual need. This is monitored frequently using the glucometer machine.
There are many kinds of Oral medications. Type 2 diabetics can sometimes control their blood sugar with this type of medications. The importance of checking blood sugars, following diet, exercising and taking medications at prescribed times is very important. If the Person does not follow their diabetic regime they too can end up on insulin.
This is such a big factor with diabetics. Many times we see type 2 diabetes coming from obese people. People who have very little exercise in their lives. Some type 2 diabetes be stopped with something as simple as weight loss and exercise.
Eating meals at the same time each day can help keep blood sugar levels in the target range. Persons with diabetes often need to eat snacks during the day and before, during, or after exercise. For example crackers with peanut butter, cheese, pretzels, or apples. There are food exchanges to allow a bigger freedom of choice and less potential to eat what ever the diabetic wants.
Eye Complications; Diabetes is the leading cause of blindness in adults between 20 and 74 years of age.
People with diabetes experience higher rates of cataracts and glaucoma.
The cost of blindness from diabetes amounts to 75 million dollars a year, from loss of wages and welfare costs.
About 4,00 people with diabetes are blind and there are about 6,000 new cases of blindness related to diabetes yearly.
25% of all new cases of end stage renal diseases are related to diabetes.
The cost to Medicare for end stage renal disease related to diabetes is estimated at 300 million yearly.
After 15 years of diabetes 1/3 of all insulin dependent diabetics develop kidney disease, 1/5 of non insulin dependent cases.
People who develop diabetes during childhood die of renal disease 500 times the expected rate.
Renal disease kills over 50% of insulin dependent diabetics.
Peripheral Vascular (PVD) Complications:
After 20 years of diabetes, 45% have PVD, this is 4-7 times more frequent then the general population.
40- 45% of all nontraumatic amputations yearly are related to diabetes, with a medical cost of over 300 million dollars.
People with diabetes are twice as likely to die of heart disease.
The incidence of stroke for people with diabetes is 2-6 times higher than the general population, after the stroke the survival rate of the diabetes is also cut in half.
The death rate in infants of mothers with diabetes is 2-3 times higher then those in the general population
Congenital malformations are also 2-3 times higher in mothers who are insulin dependent diabetics.
Diabetes, a hidden and sometimes silent killer.
Education and compassion are so very important with the diabetic patient. Remember diabetes changes a persons life, we as health professionals can make a difference in the diabetics life, if we try..
Thank You, and God Bless you....